How did Dr. Carlos Flores-Mir solve the anterior crossbite in early mixed dentition case?
April 14, 2015
On March 16, we posted a case conference by Dr. Carlos Flores-Mir about anterior crossbite in early mixed dentition. We then requested your feedback on how to manage this case and if there was any additional information that is missing and that you would need to manage such a case.
In the present video, Dr. Carlos Flores-Mir highlights a summary of the feedback that we received including your suggestions about missing information and suggested treatments. Then, he describes how he treated the case.
View the initial case conference post
Dentists’ responses to the case conference questions
Watch the Video
Hi Dr. Flores. Very interesting case; emphasizing the role of gingival tissues in dental equilibrium is what I learned from your presentation. Thank you for sharing. There was a question on the tongue function/dysfunction and it seems that the patient exhibits normal tongue thrust swallow according to you. You also mentioned that the breathing pattern is mostly nasal. Is there a reliable method to evaluate the breathing pathway? It seems that her anterior gingivae are glossy and swollen. I am curious about the tongue position which is apparent in the cephalogram. Would you consider it a low tongue posture and if it is, what is causing it? Can it be influencing the growth of the mandible in a downward and forward direction? Is the tongue ankylosed (tongue-tied) or restricted in its movement due to short lingual frenum? You mentioned that her parents are Class II skeletal pattern. If the skeletal class III is not genetic, what is the etiology in this case? If you will plan to utilize facemask, what would be the prognosis considering that the incisors are highly compensated already.
Thanks Marlon for following up the case. Breathing is a complex physiological function. Just the fact that “x” amount of air is circulating through the upper airway does not mean automatically that there are no problems. How it circulates, how long does it take, etc. are further considerations. I do believe that the primary evaluation of airway should be left to the specialists, namely ENTs. We may be able to screen for potential upper airway problems, but proper referral should be the next logic step. Regarding tongue posture in a lateral cephalogram, the question is if it is indeed what we have or it is a temporary position during imaging due to different factors. Keep in mind that tongue function and its impact is a continuous action that is not properly reflect in a 2D snapshot. Finally regarding facemasks there is controversial information out there. Unless skeletally anchoraged, there are good chances that the movement will be mostly dental and this upper incisors are already proclined as noted. How much real maxillary protrusion would it happen? We just do not seem to be able to consistently predict it. On top of that if the mandible keeps growing forward would a 3-4 mm maxillary advancement, if it happens, would it make any difference. Sometimes wait and observe is the best route, but you need to be ready to face some disappointments on the journey. Carlos
Carlos.
Thanks for discussing this very interesting case. This young lady truly has a Class III Dentofacial Deformity with severely proclined maxillary incisor and retrognathic maxilla. Are you concerned about the long term stability of these proclined teeth and future periodontal status? With further Orthodontic therapy could root resorption and bone loss on the buccal on the maxillary incisors become a problem? What will the future occlusal load do to these teeth that are so severely proclined? Being she is so young it is unlikely that her jaw relationship will improve. The best is no change but I anticipate more severe Class III DSD for this young girl in the future. What is your plan when this occurs?
Interested to hear what you have to say.
Cheers,
Kevin
There is indeed a moderate significant maxillary retrusion in this case. The provided treatment did only address the OB and OJ situation, but did nothing to address the skeletal imbalance. Is this the right way to do it? The big question in cases like this is how much more deficient will the maxillo-mandibular relationship turn in the future. A good 6-8 years of further mandibular growth are expected. If we had intervened, let’s say with a reverse pull headgear, and protrude the maxilla 2-3 mm would it make such difference a big difference in the future? If the mandible does not further move forward this early skeletal treatment may be a different maker, but if the mandible keeps growing forward we would be in continuous chasing mode. The answer will not become clear until the end of the craniofacial growth. An orthognathic surgery with at least a maxillary advancement will always be an option later. To act or not to act is the question. Thanks for following up. Carlos